Health economic aspects of minimally invasive surgical techniques

The aim of this thesis was to compare minimally invasive- with traditional open surgical techniques for various diseases with regards to cost-effectiveness. Health economic evaluations were performed using data from clinical trials and routine care data from registers. The healthcare perspective was represented in all four studies and the societal perspective (including sick-leave costs) was represented in three out of four studies. Paper I included a cost-minimization analysis of laparoscopic and open surgery as treatment for rectal cancer within the randomized, controlled COLOR II trial. From the healthcare perspective laparoscopic surgery was costlier while from the societal perspective no significant long-term difference was observed. Paper II included a cost analysis of laparoscopic lavage versus Hartmann’s procedure as treatment for complicated diverticulitis with purulent peritonitis within the randomized, controlled DILALA trial. Laparoscopic lavage was considered less costly both at 12 months and throughout patients’ expected life, from the healthcare perspective. Paper III was a cost analysis of robot-assisted laparoscopic prostatectomy (RALP) versus open surgery for prostate cancer within the prospective trial LAPPRO. RALP was associated with a higher mean cost than open surgery from both the healthcare and societal perspective at 24 months. Paper IV was a prospective cohort study of cost-effectiveness for laparoscopic versus open surgery as treatment for colorectal cancer, with resource use data and unit costs derived from Swedish national registers. Laparoscopic surgery was associated with better clinical and cost outcomes from both healthcare and societal perspectives at 12 months after primary surgery. Minimally invasive surgery can be cost saving compared to conventional open surgery. It is advisable to perform economic evaluations in routine care, as cost-effectiveness of surgical techniques most likely will change over time

Health Economic Analysis of Open and Robot-assisted Laparoscopic Surgery for Prostate Cancer Within the Prospective Multicentre LAPPRO Trial

Background: The rapid adoption of robot-assisted laparoscopy in radical prostatectomy has preceded data regarding associated costs. Qualitative evidence regarding cost outcomes is lacking. Objective: This study assessed how costs were affected by robot-assisted laparoscopic prostatectomy (RALP) compared with open surgery. Design, setting, and participants: Cost analysis was based on the dataset of the LAPPRO (Laparoscopic Prostatectomy Robot Open) clinical trial, which is a prospective controlled, nonrandomised trial of patients who underwent prostatectomy at 14 centres in Sweden between September 2008 and November 2011. Currently, data are available from a follow-up period of 24 mo. Intervention: In the LAPPRO trial, RALP was compared with radical retropubic prostatectomy (RRP). Outcome measurements and statistical analysis: Costs per surgical technique were assessed based on resource variable data from the LAPPRO database. The calculation of average costs was based on mean values; Swedish currency was converted to purchasing power parity US dollar (PPP$). All tests were two-tailed and conducted at α = 0.05 significance level. Results and limitations: The cost analysis comprised 2638 men. Based on the LAPPRO trial data, RALP was associated with an increased cost/procedure of PPP$ 3837 (95% confidence interval: 2747–4928) compared with RRP. The result was sensitive to variations in caseload. Main drivers of overall cost were robotic system cost, operation time, length of stay, and sick leave. Limitations of the study include the uneven distribution between RALP and RRP regarding procedures in public/for-profit hospitals and surgeon/centre procedural volume. Conclusions: Based on the LAPPRO trial data, this study showed that RALP was associated with an increased cost compared with RRP in Swedish health care. There are many factors influencing the costs, making the absolute result dependent on the specific setting. However, by identifying the main cost drivers and/or most influential parameters, the study provides support for informed decisions and predictions. Patient summary: In this study, we looked at the cost outcome when performing prostatectomies by robot-assisted laparoscopic technique compared with open surgery in Sweden. We found that the robot-assisted procedure was associated with a higher mean cost. This cost analysis reports that compared with open surgery, robot-assisted laparoscopy for prostate cancer was associated with a net increase in cost. One important conclusion is that widespread implementation of costly new techniques should not precede outcomes from well-designed trials